Patient perspectives on considerations, tradeoffs, and experiences with multiple myeloma treatment selection: a qualitative descriptive study

Background Advances in multiple myeloma treatment and a proliferation of treatment options have resulted in improved survival rates and periods of symptom-free remission for many multiple myeloma patients. As a result, health-related quality of life (HRQoL) concerns related to myeloma treatments have become increasingly salient for this patient population and represent an important consideration guiding patients’ treatment choices. To gain an understanding of patients’ experiences with choosing myeloma therapies and explore the HRQoL concerns that are most important to them, we interviewed a diverse sample of US-based multiple myeloma patients about their treatment considerations. Methods We conducted a qualitative descriptive study using in-depth interviews. Participants reflected on (1) the factors that were most important to them when thinking about multiple myeloma treatment and how these have changed over time, (2) how they might weigh the importance of treatment efficacy vs. side effects, (3) trade-offs they would be willing to make regarding efficacy vs. HRQoL, and (4) treatment changes they had experienced. Interviews were audio-recorded and transcribed, and narratives were analyzed using applied thematic analysis. Results We interviewed 21 patients, heterogeneous in their disease trajectory and treatment experience. Participants were 36 to 78 years, 52% female, and 38% Black. Efficacy was named as the most important treatment consideration by almost two-thirds of participants, and over half also valued HRQoL aspects such as the ability to maintain daily functioning and enjoyment of life. Participants expressed concern about potential treatment side effects and preferred more convenient treatment options. Although participants stated largely trusting their clinicians’ treatment recommendations, many said they would stop a clinician-recommended treatment if it negatively impacted their HRQoL. Participants also said that while they prioritized treatment efficacy, they would be willing to change to a less efficacious treatment if side effects became intolerable. Conclusions Our findings link to other reports reflecting considerations that are important to multiple myeloma patients, including the importance placed on increasing life expectancy and progression-free survival, but also the tension between treatment efficacy and quality of life. Our results extend these findings to a racially diverse US-based patient population at different stages in the disease trajectory.


Background
Multiple myeloma is the second most common hematologic malignancy [1] and accounts for about 10% of all blood cancers [2]. In 2021, it is estimated that 34,920 new cases will be diagnosed in the United States, and about 12,410 deaths from myeloma will occur [3]. At a population level, multiple myeloma is slightly more prevalent in males [4] and has been found to occur twice as often in Black Americans than White Americans [5].
Recent years have seen rapid evolution in myeloma treatments [6], such that patients now have access to a wealth of treatment options [7] and have realized corresponding improvement in survival rates [8]. It is now common for myeloma patients to experience periods of symptom-free remission during which they continue to undergo maintenance therapy, although most patients eventually relapse, and the periods of remission shorten between each treatment cycle [9]. While multiple myeloma remains incurable, these advances have meant that many patients now experience it as a chronic disease, rather than as one that is rapidly terminal [10].
Improved survivorship has also given more salience to quality of life concerns [11,12], as living longer has necessarily shifted patients' focus away from worry about immediate mortality and towards the need to deal with disease-related symptoms and treatment side effects on an ongoing basis [13]. Cumulative toxicity and adverse effects related to treatment, as well as considerations related to treatment administration, thus increasingly serve to guide patients' treatment choices [14,15].
To gain an understanding of patients' experiences with multiple myeloma and explore the values and issues that are most important to them, many researchers have turned to qualitative methods to document myeloma patients' perspectives and experiences [16]. Qualitative studies have also been used to examine patient preferences for myeloma treatment options [17,18]. However, the bulk of qualitative research into myeloma patients' treatment preferences has been conducted with European patient samples; studies of US-based patient preferences are lacking. Further, none of these studies has purposefully sought to include non-White participants, aiming to obtain a sample more representative of myeloma distribution in the general population.
In this manuscript, we describe findings from qualitative interviews with diverse multiple myeloma patients in the US on considerations, including health-related quality of life (HRQoL) concerns, that may affect their decisions to change or continue taking multiple myeloma therapies. The findings were subsequently used to develop a discrete-choice experiment (DCE) survey to estimate patient tradeoff preferences for features of multiple myeloma therapies and evaluate patient tolerance for issues associated with treatment continuation or change; the DCE findings will be reported elsewhere.

Study design and participants
We conducted a qualitative descriptive study [19,20] using in-depth interviews (IDIs). Study participants were English-speaking US adults aged 18 years or older with a self-reported or physician-confirmed diagnosis of multiple myeloma. Participants were recruited via email invitations sent to members of the multiple myeloma registry within the Cancer Support Community (CSC), an online panel of patients (https:// www. cance rsupp ortco mmuni ty. org/ regis try) who have agreed to participate in research, and via clinician referral from a single center Adult Blood and Marrow Transplant Clinic in North Carolina. Among eligible participants, we purposefully selected [21] and invited individuals for interviews based on desired background and demographic characteristics (i.e., relapse status, race, and gender), with a specific goal of recruiting Black patients to approximate the proportions of Black multiple myeloma patients in the US general population. The interview sample size was informed by the concept of informational power [22], which outlines five factors to consider when determining sample sizes for qualitative research, such as the scope of the study aim and specificity of participant experiences.

Data collection
Two trained qualitative interviewers conducted oneon-one interviews by telephone from July 9, 2019 to June 18, 2020. Questions explored participants' perspectives on and experiences with multiple myeloma and its treatments, with a focus on decisional considerations and quality of life concerns (see Appendix for selected questions from the interview guide that informed this analysis). We asked participants to describe the course of their multiple myeloma treatment, the factors that were most important to them when thinking about multiple myeloma treatment, and how these have changed over time. Participants who had experienced a relapse since diagnosis and treatment initiation were asked to focus only on the factors that were most important to them since relapsing. When discussing the factors that were of greatest importance to them, participants were also asked to consider whether they would want a cancer treatment with fewer side effects even if less effective than other treatments, versus the most effective treatment even with many side effects. Further, we asked participants about trade-offs they might choose to make regarding treatment efficacy versus quality of life; these included: 1) situations in which they might consider stopping a treatment recommended by their clinician, and 2) whether they would give up an effective treatment with many side effects in favor of a less effective treatment with fewer side effects. We also asked participants to describe their experiences, if any, with treatment changes. All interviews were audio-recorded with participants' permission and lasted approximately an hour.

Data analysis
Descriptive statistics were used to summarize participants' demographic characteristics. Participants' narratives were analyzed using applied thematic analysis [23]. Interviews were transcribed verbatim following a transcription protocol [24], and NVivo version 12 [25](QSR International) qualitative data analysis software was used to organize the data and apply codes [26] to the transcripts. Trained qualitative analysts, who were also the interviewers, first independently applied structural codes based on the interview guide, segmenting participants' interview narratives into broad categories related to the overall objectives (e.g., most important considerations for treatment). Inter-coder reliability (ICR) was assessed on 20% [27] of transcripts during the structural coding phase, discrepancies in code application were resolved through discussion, and any agreed-upon revisions to the structural coding were made. Next, the data were further subdivided into content codes, as the analysts identified themes within each structural code that reflected specific patient experiences and applied these to the transcripts. ICR assessments were conducted on 20% of transcripts during this stage of analysis as well, following the same procedure as before. After coding was completed, the analysts placed content codes into emergent thematic groups to identify common experiences among participant narratives and wrote analytical summaries of salient themes, including illustrative quotes. As no descriptive differences between Black and White participants were observed during analysis, all results thus reflect the interview sample as a whole. The COREQ checklist [28] informed the development of this manuscript.

Ethics
The Duke University Health System Institutional Review Board (IRB) reviewed and approved the protocol (Pro00094133). All participants provided verbal informed consent.

Study participants
We interviewed 21 people with multiple myeloma. Participants' ages ranged from 36 to 78 years, 52% (n = 11) were female, and 38% (n = 8) were Black. All participants had graduated from high school, and 67% (n = 14) had a bachelor's degree or higher. Most participants (n = 15; 71%) were retired or not currently working ( Table 1). Fifteen participants (those recruited from CSC) self-reported having a physician diagnosis of multiple myeloma, while the six participants recruited from the transplant clinic had a confirmed diagnosis. Self-reported dates of diagnosis ranged from 21 years to 1 year prior to the interview; the majority (n = 14; 67%) were diagnosed within the previous 6 years. Slightly more than half (n = 11; 52%) of participants reported that they had experienced one or more relapses of multiple myeloma since diagnosis and treatment initiation, and 33% (n = 7) indicated that they had changed treatments.

Most important treatment considerations
Almost two-thirds of participants stated that their most important factor when considering treatment options was treatment efficacy. Participants explained that while it was important to them to balance quality of life impacts and other medical concerns to the greatest extent possible, they ultimately wanted a treatment that would be the best option to treat their cancer. A few participants specifically elaborated that their goal was to stay alive and expressed that they would be willing to tolerate adverse treatment effects if the treatment would allow them to live longer. See Table 2 for participant quotes.
However, HRQoL remained an important consideration for participants. Just over half of participants stated that they also considered quality of life aspects such as the ability to function (described as being able to continue working and engaging in usual daily activities), the ability to enjoy life (including engaging in social and leisure activities, spending time with others, and being present for important life milestones), and not feeling sick (including both minimization of treatment-related side effects and alleviation of multiple myeloma-related symptoms), when considering potential multiple myeloma treatments. In particular, participants raised concerns about the possibility of experiencing treatment-related side effects, with nearly a third describing this as an important factor in their thinking. For example, participant worries included the potential for fatigue and mental fog that might make it difficult for them to function, or the possibility that treatment might damage other organ systems such as kidneys that had already been compromised by the multiple myeloma. Some participants described that while they considered a variety of factors when selecting a cancer treatment, the most convincing argument in favor of a particular treatment was ultimately their hematologist/oncologist's recommendation. These participants elaborated that they trusted their clinician to understand what was important to them and help them strike the right balance between side effects and efficacy. They explained that the clinician was the expert, they perceived the clinician as having their best interests at heart, and that treatments previously recommended by the clinician had proven effective. Convenience and ease of treatment administration also factored into a few participants' decision-making, as they described that making frequent return visits to the clinic was disruptive to their schedule, particularly for those who were trying to return to work. Thus, these participants preferred less-frequent treatment regimens or would prefer to receive treatment in a form (e.g., orally) that could be administered at home without the presence of medical personnel.
While some participants described a single primary consideration that influenced their treatment decisionmaking, most explained that they considered and weighed a variety of personally important factors when choosing a multiple myeloma treatment. This pattern continued when participants were asked how their treatment considerations had changed over time, with most describing that they continued to consider multiple factors. However, while a few noted no change to their treatment considerations, most described changes in the relative importance of different factors. For example, a participant expressed that over time, quality of life considerations and convenience of treatment had taken on greater significance for them, while another noted that as time passed, they had become willing to be more aggressive with treatment in order to have a better chance of eradicating the cancer.

Tradeoffs
More than half of participants indicated that they would stop a clinician-recommended multiple myeloma treatment if it would negatively affect their quality of life. "Concerns" or "reasons to stop" included intolerable side effects such as feeling excessively ill, adverse treatment-related impacts on participants' ability to function, and the potential for the treatment to cause future harm, such as development of other cancers, or damage to organ systems. A few participants also discussed that they would consider treatment efficacy in this scenario, noting both positive and negative considerations that might lead them to stop treatment, including if a better treatment became available or conversely, if prognosis was poor despite the treatment. See Table 3 for participant quotes.
Most participants expressed that they would not trade a more efficacious treatment for one that had fewer side effects but was less effective, echoing participants' earlier statements about prioritizing treatment efficacy.  Participants described wanting the best option available to treat the cancer, not wanting to interfere with a treatment that was working for fear the change might cause the multiple myeloma to come back, and not wanting to experiment if they were able to effectively manage side effects. Some participants also discussed wanting to avoid longterm myeloma-related damage that might occur with a less effective treatment, noting that if a treatment were not strong enough to keep all of the adverse effects of multiple myeloma at bay, they might sustain lifelong damage to bones or kidneys as a result of choosing a treatment with fewer side effects. A few participants stated definitively that they would not be willing to change from a treatment that was working or that they might even be willing to accept a treatment with a worse side effect profile if that treatment were also more effective or aggressive. However, some participants tempered their comments by stating that their willingness to stay on the most effective treatment would depend on the severity of side effects experienced. These participants would be more willing to change to a less effective treatment if they were experiencing intolerable side effects or if the more effective treatment had a high risk of harmful side effects. The duration of treatment also factored into some participants' thinking. Several described that they would be willing to tolerate aversive treatment effects for a period of up to several months, but none volunteered that they would be willing to experience these effects for as long as a year. Participants discussed that they would engage in a continual process of re-evaluation after a certain time point, to determine whether they felt able to continue with the treatment.

Experience with treatment changes
More than half of participants stated that they had not asked or thought about asking their hematologist/ oncologist to change their myeloma treatment, largely because their current treatment was working or they trusted their clinician's recommendation about the most appropriate therapy. Some also described that they had not made a treatment change out of worry that changing treatments would cause progression or relapse of their disease. However, around a third of participants indicated that they had experienced a treatment change. Further, a few noted that although they had not yet changed treatments, the impending need to do so was an ongoing topic of conversation with their clinician. See Table 4 for participant quotes.  Treatment changes were often necessitated by signs that a medication had stopped working or was becoming less effective at suppressing the myeloma. Participants also discussed making treatment changes in response to side effects. The most commonly described changes were dosage adjustments or switching to a different myeloma treatment; a few participants noted that they had experienced both types of changes. Side effects also led to temporary or permanent treatment stoppage for a few participants, who discussed that they had taken a break or stopped treatment because of adverse reactions. A few participants additionally described that their preferences for oral routes of administration or decreased administration frequency led to a treatment change.

Discussion
Our findings reflect factors and considerations that are important to patients undergoing multiple myeloma treatment in the US. The study sample included racially diverse participants, as well as those representing different stages of the disease trajectory. Participants emphasized the primary importance of treatment efficacy and their desire for the best option to treat the cancer, yet their narratives also highlighted concern that effective treatment might entail sacrificing aspects of HRQoL. The need to balance efficacy with quality of life, finding a treatment that allows for good myeloma control while also enabling as much normal functioning as possible, was commonly expressed. Participants shared that they wished to avoid future harm from myeloma and its treatments, did not want to feel sick or experience other aversive side effects, and did not want to be unduly burdened by the mode or frequency of treatment administration. Participants also expressed that their hematologist/ oncologist's treatment recommendation served as an important consideration and that they trusted their clinician to suggest treatments that reflected their values.
Similar findings to ours have been obtained in European and Canadian patient samples, in studies using a variety of methods to elicit treatment preferences from myeloma patients. Several studies have highlighted the importance to patients of progression-free survival and increased life expectancy [15,17,29,30]. For example, Mühlbacher and colleagues conducted focus groups for concept elicitation followed by a survey of 282 patients in which the relative importance of various multiple myeloma therapy characteristics was assessed via both Likert scale and DCE; on both measurements, patients ranked elements related to treatment efficacy and prolonged life expectancy as most important [29]. In another study that used an online survey of 560 patients to examine preferences for multiple myeloma treatment attributes, Postmus and colleagues found that increasing the probability of surviving progression-free for a year or longer was weighted more strongly by patients than was the probability of decreasing either mild/moderate chronic toxicity or severe/ life-threatening toxicity associated with treatment [30].
Other qualitative interview studies with myeloma patients have also reported on the tension many patients experience between treatments that prolong life but produce disruptive side effects [15,17,18]. A group of Canadian patients who were interviewed about their experiences living with relapsed or refractory multiple myeloma expressed that while life expectancy was one of their highest treatment priorities, physical and cognitive side effects related to treatment were also significant for their potential impact on functioning and quality of life, and as with our sample, some patients in this study described that their treatment priorities changed over time [17]. A recent focus group study of patients in four countries [18], seeking to identify key attributes impacting myeloma patients' treatment choices, also described participants' perspectives on the importance of balancing life expectancy with the experience of side effects that could negatively impact quality of life. Patients in this study echoed concerns voiced by our sample about trading short-term benefits for long-term negative effects and expressed that duration and severity of side effects might induce them to consider a treatment change.
Our findings also support data from other studies [15,31] showing that frequency and mode of administration are important considerations for myeloma patients. A DCE study of relapsed refractory myeloma patients in Germany found that mode of administration was considered an important aspect of patients' quality of life; specifically, these patients preferred oral treatment that avoided the need for them to undergo lengthy in-clinic infusions [31]. Patients in another recent multi-country interview study also described burden due to duration of infusions and travel time to the clinic; these patients expressed a preference for in-home treatments, where available [15].
In our sample, a few participants described engaging in ongoing dialogue with their hematologist/oncologist regarding future treatment changes, illustrating the shared decision-making (SDM) approach to treatment choice; participants also expressed trust that their clinician's judgment about the most appropriate treatment would reflect their values. Unfortunately, studies have shown that many clinicians may not follow an SDM framework in clinical practice, instead falling back on one-sided informational presentations [32]. Our findings highlight the importance of operationalizing and following an SDM process with multiple myeloma patients, thus ensuring that patients' goals and preferences are utilized to inform clinicians' treatment recommendations.
Our study links to many others in the literature that have reported on the treatment-related benefits, quality of life impacts, and burdens that matter most to multiple myeloma patients, confirming and extending these findings to a US-based patient population that intentionally included non-White participants. The racial diversity of our sample, as well as its heterogeneity with respect to disease stage and treatment experience, represent strengths of our study. However, the limitations of our research must also be considered. As a qualitative study with 21 participants that were purposefully sampled, a different group of participants may have shared different experiences. Further, the self-selection of much of our sample from an online panel of cancer patients may have resulted in a sample that was more engaged and knowledgeable about treatment options than myeloma patients at large. Finally, participants self-reported their disease history, and some were not able to describe the specific details about their cancer course and multiple treatments. This is mitigated, however, by the fact that our focus was on treatment considerations and experiences that apply to myeloma patients generally, without reference to specific disease stage or relapse history.

Conclusions
In conclusion, our qualitative interviews on participants' experiences with multiple myeloma treatment and the considerations that are most important to them revealed that while participants placed high value on treatment efficacy, maintaining quality of life was of almost equal importance. Participants' tradeoff considerations were driven by the desire to maintain health and functioning, avoid future harm, minimize adverse treatment effects, and maximize convenience. Participants also expressed trust in their hematologist/oncologist's recommendations and viewed their clinicians as well positioned to understand and reflect their values when suggesting treatments for multiple myeloma. Operationalizing patients' treatment preferences via a shared decision-making framework is recommended.